BREAKING SIGNIFICANT NEWS Jennie Quiddington Chapter 7
Introduction • This presentation identifies the requirements for successfully breaking significant news • Part 1 – Overview • Part 2 – Process • Part 3 – Skills for Breaking Significant News Effectively • Part 4 – Reaction and Follow-Ups
Definitions BAD NEWS: Inauspicious information causing suffering with regard to an individual’s view of their future. Our problem is that there is often limited ability to anticipate how the news may be accepted by the recipients. The word ‘SIGNIFICANT’ is an alternative. This implies that the news may affect the recipients in more diverse ways than the news breaker may consider.
Empowerment Telling the recipient what will happen and what to do is inappropriate. We need to consider the individual’s psychological and emotional responses to the news. Empower recipients to make their own decisions based on knowledge, personal experience and a constructive relationship with the healthcare professional. Success in this activity will contribute to the recipient’s ability to trust healthcare professionals in the future. The ability to break significant news in a manner that is recipient centered, constructive and establishes a positive patient/carer relationship takes considerable skill. Wondrak (1998) identifies the need of health workers to be confident in their communications with patients to develop therapeutic relationships.
Self Awareness Your own concerns about delivering significant news may affect your behaviour, meaning information is not conveyed in the most appropriate way for the patient. Be especially aware of: Giving information at the expense of the recipient’s need for emotional support. This can come from a fear of overlooking important information. Make sure there is an opportunity for them to ask questions before the meeting ends. Anticipating the patient’s response based on your own hopes or fears (e.g. assuming news of pregnancy always welcome). Withholding information for fear of the patient’s reaction (and potentially, your own response to that). It’s worth remembering that most recipients will interpret your tears as evidence that you are compassionate. .
Q. In your learning groups, reflect on these statements to identify how your attitude and behaviour may be affected by preconceptions. ‘I know more about this issue than the recipient’. ‘I have only got 5 minutes to tell them and the corridor will have to do as the office is being used’. ‘I’m able to give hope when the situation is bleak’. I’m not the person to give this news, as I don’t know enough about it’.
There are hidden factors that may be activated in you and the news recipients that affect attitudes and behaviour in both. Everyone has "personal baggage" that affects how they respond’. • Be aware of the factors that influenced your career choice. Have you had experience of health or social care problems? If the experiences have been unresolved through the mourning process, a person with a similar problem can trigger the past experience of the healthcare professional. • Recipients will bring their previous experiences of healthcare and others who have held power over them to the situation. Our professional status gives great power and this may trigger behavioural and emotional responses that belong to the recipient’s former experience.
Q. In your learning groups, reflect on these statements of unconscious baggage to identify how attitude and behaviour may be affected: • Major barriers: social status, race, age, spiritual beliefs, gender and personal experience • ‘Subtle barriers: embarrassment, shame, fear, anxiety, amount of experience’. • Unresolved family problems: ‘Inability to respond to the recipients’ emotions or handle difficult family issues’. • Dependency: ‘The news may affect our good relationship’. • Guilt: “I encouraged them to think it would all be ok”.
Setting • The optimum location should be quiet, private, warm and • comfortable for all. • Ensure: • Sun does not move into a position which causes irritation • Seating enables people to sit, relax and get out of the chair easily. • You all sit without barriers such as desks or tables • Give personal space (one metre around body). Distress increases need for personal space • Anticipate how many people will attend. Try to accommodate the recipient’s support network and staff • If the location cannot be changed, advise the recipients so they can choose who is to be present • Avoid intrusions: Turn off phones, use “do not disturb” sign • Do not leave recipients until agreed, ask other staff to take messages.
Planning • Before you approach the recipients, you need to plan how you are going the run the session • Setting appropriate boundaries contributes to a feeling of security • Schedule ample time for delivery of news, and any questions • Negotiate a time to suit the recipient, their support network and staff involved in their care • If children are to receive news, their parents must be present • If taping the session, give a copy to the recipient before leaving or provide written information: reading may help to clarify complex matters • Identify how the patient can receive future test results • Locate support details to provide about treatment, medication, facilities, support networks and prognosis • Allocate time for the patient to talk with you alone • If the partner/parent are the problem try to prevent them attending • Make next appointment and plan how meeting may proceed • Provide a contact telephone number to access support
Skills • Speak clearly, avoiding complicated technical terms, jargon and abbreviations. Use an interpreter if necessary. • Set all boundaries at the beginning of the meeting. • Prepare them for distressing news: "I am afraid I have news that may be difficult to accept." • Use a gentle tone of voice, identify their upset and express sadness. • Explore how they received your news. Identify correctly understood information and gently educate misconceptions. • Exhibit sensitivity: avoid probing questions, give them time to consider and respond to the news. • Respond appropriately: If they are angry avoid defensiveness, if they feel we understand our support will be more effective.
Preparing • During the session you may be confronted with a variety of responses to the news you are delivering. • Develop your vocabulary: words appropriate for you and the situation. • Question the recipients without intimidation. • How much do they know or want to know? • Little news may be retained. Repeat with their support network present. • Corroborate bad news rather than deliver it. Avoidance of acknowledging problems indicates denial which needs addressing. • Discuss dying. They need facts regarding types of deterioration and what facilities are available as the patient approaches/reaches death. • Some news delivery leads to a reluctance to ask questions, inability to discuss or avoiding hearing. Change delivery technique/encourage participation. • What they say and ask or how they react to the news determines how much is said. Offer options for treatment and care to give hope.
Problems • Failure to provide sensitivity, support, honesty and realism with hope can lead to the recipient experiencing fear, anxiety and despair. • Withholding the incurable nature of an illness, or treatment side effects, will prevent recipients planning their lives with their support network. • Failure to ask if they understand the information may result in them leaving having misunderstood or not heard the information. • Family interference can manifest as a request that significant information is withheld or manipulated in some way. • Excessive bluntness can be due to the location or time available not being conducive to in depth discussions • Deterioration of the recipient/carer relationship and failure to utilise available treatment for problems may result.
Delivering significant news • Patients need to believe that they can face the possible fight for life ahead of them, knowing you are working alongside them as they face their uncertain future. • Maintain regular eye contact but avoid constant contact, as it is difficult to think clearly if you experience someone staring at you. • Position chairs so you are not directly opposite the recipient’s, so you can look away from each other without turning your head. • Identify words you can use to convey support and empathy to all recipients. • Never say "there is nothing more to offer“, as this creates a sense of abandonment. • Maintain a consistent, relaxed, warm and open approach to whatever the recipient wishes to discuss. • Empathy enables recipients to know you understand them. Communicate that you understand their position, hopes, feelings and ideals.
Communication Techniques • Techniques from the counselling profession. • See the Communications Chapter for more skills. • Touching is a boundary issue, not everyone enjoys to be touched. Ask if they would like this or find it an intrusion into their personal space. If they refuse do not touch them regardless of their distress. • Reflection: Repeat back key words to give them an opportunity to say more. Over use can cause irritation. • Paraphrasing: Reformulate what they say and repeating it back to them. May reveal hidden emotions that increase your understanding. • Clarification: Check you understand what they said, aids precision and avoids errors when responding to questions or documenting the meeting. • Summarise your news: Improves understanding and helps if news causes confusion. Repeating key points is often helpful and necessary.
Hope • To achieve a realistic level of hopefulness, we need a balance between hoping for the best and preparing for the worst. • Emphasis on hope can deny patients the opportunity to explore their wishes, fears, discuss dying, and how they want to continue their lives. • Share hope, align yourself with the patient and provide support. • We need not share a patient’s hopes and fears to respect, learn about, and respond to them. • Patients that feel their life has purpose and meaning are more able to cope with difficult news. • Honesty, not false reassurance, is the best way to establish hope. • Recipients can use therapies such as reflexology, massage or psychotherapy to give independent action away from mainstream healthcare. • We need to ensure the recipients visit qualified members of these therapies who can act as extra therapeutic support.
Positive and Negative Responses • How the recipient receives the news may have implications on their future healthcare. • Acceptance often manifests itself as a desire to explore treatment options and become active in care. • Decreased anxiety and uncertainty brings relief. Perception change manifests as hope that future result are positive. • There is realistic acceptance of the probable life span, yet a desire to live life at its optimum level. • Accepting help to address emotional/spiritual issues and focusing on symptom management can enhance a patient/carer relationship. • Negative responses are the opposite of the above and can manifest as “ I want to give up”. • Negative reactions: inform other healthcare professionals of concerns regarding the possible psychological responses or negative activities by the recipient.
Defining and Exploring Barriers • Explore what barriers the patient constructs to inhibit their ability to use our facilities, pharmacological, medical or surgical options • Relatives request information is withheld from the patient: Communicate with the patient’s support network/healthcare professionals. Is this is in patient’s best interests? • Support recipients to inform their family: members will be better prepared when physical or psychological changes occur in the patient. • Provide information to relatives: misconceptions are challenged or enable them to start activities suited to a relative whose life expectancy has been shortened. • Fixed life expectancy can impair the remaining time for all. • Uncertainty as to when life ends may be a prerequisite for life to have meaning and value, as well as lowering stress and anxiety for all.
Future Developments • We need to offer options, identifying what is possible and, once the plan is made, what activities it will entail. • Choices need to be made by the recipient and we must be respectful of their wishes. • Sensitively challenge their decisions if barriers they erect prevent them from accessing treatment. • Bad news may result in complex problems for the recipient or their support network. Prioritise problems so they are dealt with in an appropriate order. • Tackle some problems during a later visit to give them time to identify specific areas of concern. • Obtain expert advice and include other members of the multidisciplinary team if they are required. • Establish the next appointment and a format for how the discussion may proceed.